The Rejuvenation of Medical Ethics

by Frank Barbour Wynn

The Physician

"the rejuvenation of medical ethics"^[1]

Frank B. Wynn

Indianapolis

Perhaps there is no phase of medicine concerning which there is so much misinformation as concerning the commonly designated "Code of Medical Ethics". Almost without exception, intelligent people know of the existence of a pact amongst decent practitioners, but the knowledge is vague. Some entertain the view that it is a sort of oath; others that it is a traditional custom descended from the ancient fathers in medicine; quite general is the opinion that it is an unwritten law of the profession containing obsolete rules of conduct, neither justified in wisdom nor right, but which long usage makes it impossible to shake off. In the lay press the view is often expressed by inuendo if not by direct words, that "Medical Ethics" is a species of folly characterized by narrowness, not at all in keeping with the spirit of modern progress. By those outside the pale of organized medical forces, this idea is held aloft and painted with ridicule. Should there not be some concerted and forceful effort made to correct these erroneous ideas entertained in the public mind?

How remote these conceptions are from the truth, all know who are familiar with the Principles of Medical Ethics. It represents a most commendable effort on the part of the intelligent and progressive elements of medicine, to conserve the idealism of the medical past. It seeks to elevate the standards of practice and scientific attainment, of gentlemanly and moral conduct, for the benefit of the patient first of all; for the mutual instruction and elevation of the profession; and in the interest of the public weal. Should we ever fall from these high standards, we will no longer be worthy the designation of a profession, but must march in the ranks of tradesmen.

Searching for the causes of public mistrust of the "Code" they are found to exist in ignorance concerning its nature and purposes. Laymen are excusable for these erroneous conceptions and misapprehensions. I never yet have talked to one who had read the Principles of Medical Ethics. His knowledge of it came through hearsay or isolated acts of physicians which he could not understand, and not comprehending the rational and moral grounds for such action, he was likely to consider it queer and senseless. And so very naturally, one might say quite justly, our "Code" has come in for gibes and sneers. Physicians themselves not rarely also show their ignorance of the scope and purpose of this instrument by falling in with the public judgment and condemning it by faint praise. In truth can the profession as a whole claim that any moving faith animates the rank and file in support of this "Charter of Achievement, Responsibility and Conduct"?

Had not progressive men from time to time in the history of organized medical development, made conscientious effort to formulate "By-laws" or "Principles" as a guide to professional conduct, they would have been most recreant to duty in their day and generation. As well think of the American Commonwealth without a Constitution, a religion without a creed, or the Bible without its Ten Commandments. Our "Code" is not a perfect instrument—never can be. With evolution in medical progress it will need revision to meet the changes which wisdom and experience have proved out, and found not wanting. For the present it will be to our mutual advantage to know better our commandments of "Shalts" and "Shalt-nots".

It is surprising and rather disheartening how few medical men are familiar with the Principles of Medical Ethics. This explains why they do not more frequently come to the defense of its teaching. This is owing in part I believe to the fact of its stilted form. That it is framed by Chapters, Articles and Sections is in conformity with usage in the writing of Constitutions and By-laws. This method has its practical value in enabling one to find quickly certain articles of the instrument. But it is open to the very serious objection that it lacks in readable qualities which hold one's interest and attention. Constitutions are very important in setting forth the aims and rules of action in organizations, but who takes any particular delight in reading them? They possess a sort of stereotyped monotony of mechanism which is repellant to enthusiasm. However fine and fundamental may be the American Constitution, does one gather enthusiasm from perusing its contents, as he does from reading the Declaration of Independence? The former is cold, concise to the point of mathematical exactness, so carefully wrought that not a word can be spared. It is the bulwark of wisdom and farsight, coming out of the fertile brain of Hamilton, protecting the liberties gained at so great a price, against future calamity. It is utterly devoid, however, of appeal to the imagination or emotions. In contrast to Hamilton's master work, contemplate the immortal instrument penned by Jefferson. It burns with righteous indignation, kindles the flame of patriotic fervor and lights the torch of liberty. Who is not proud of both? One served to arouse the builders of a republic to action and having served the purpose of the day, lives now chiefly as a beautiful historic sentiment. The other became the permanent foundation upon which the governmental structure of liberty rests.

In our present state of national unrest, following the world-war, millions of unassimilated foreigners upon our shores fail to comprehend the significance of American institutions. The American Constitution, however wise and just, is a cold and meaningless thing to them. Is not the imperative duty of the hour to read into the Constitution the spirit and the fire of the Declaration of Independence in order that they may know the price paid for liberty? When we who have enjoyed these blessings are aroused by a zeal like Paul of old, to proclaim again and again upon every hand, the sacrifices and the spirit out of which and through which our country has grown, there will come to these peoples conviction and conversion. As soon as they are nationally born again they will become fit subjects to live and work under a wise governing Constitution.

By analogy may it not be said of our constitution, "The Code of Medical Ethics," that like the American Constitution, it too needs to have read into it an awakening spirit of medical evangelism—which will renew the faith and arouse to more determined influence and power in medicine. For may it not be true that we have been carried from safe moorings by the world-wide wave of materialism? The captains of industry have occupied the stage of chief interest in our day and generation. Likewise the captains of medicine have marched to material conquest in laboratories, revealing cold facts; along the avenues of specialism, searching for isolated and unemotional truths—all splendid and serviceful achievements taking little account, however, of man as a thinking, feeling organism. In the light of these facts is it not well that we should come to our medical senses, giving proper evaluation to the ethical and moral phases of medicine.

It must be granted that the Principles of Medical Ethics is a remarkable instrument comprehending the very essence of wisdom which should govern the conduct and widen the vision of every right-thinking physician. But a deplorable weakness lies in its cold, stereotyped, constitution-like manner of presentation, which repels rather than invites contemplation. Certainly it has failed to bring conviction to the public mind, which views it with ill-concealed contempt. Nay, even more. There often arises wide-spread suspicion of concerted endeavors of physicians for the common weal. Is it an impending epidemic of small-pox in which general vaccination is urged, the cynical voice of suspicion is raised, charging the medical profession with planning a vaccination harvest. Should unsanitary conditions threaten the health of the community and a courageous group of physicians take a firm stand for their correction, they may expect slanderous criticism of their motives. And among the opposition will sometimes be found the reactionary physician, who has become myopic to the broader view of Medical Ethics.

But of all the scoffers at the tenets of our medical creed, none equals in numbers or virulence of accusation the quasi-medical sects—the "rubbers" and "healers". When concerted effort is made by the profession to require of these mushroom practitioners the same fundamental literary and scientific training which accredited physicians must take, they protest furiously, crying persecution and monopoly. Thus have these anti-medical agitators and pseudo-practitioners shouted themselves into a position of prominence in the public mind. So securely established are they that legislatures pay homage in negative conduct regarding reforms, and because of their substantial contributions to the advertising columns of the lay press, the latter gives them a fattening publicity. Stoically we have suppressed our emotions and borne their brazen aggressiveness. The professional brain is dizzy with apprehensive anxiety of what may come to pass.

But let not the intensity of our zeal to punish or restrict the "irregulars" blind us to the existence of our own professional delinquencies. However venal and offensive their acts, has our conduct been above the suspicion of mercenary ambitions? Note the large number of general practitioners entering special fields, frankly confessing the motive is greater ease and larger income. Even the tendency of the time to group practice finds its most frequent argument a desire to augment incomes rather than cooperative study, and productive scientific effort. This statement is borne out by the fact of frequent failures of group efforts, from wreckage upon the rocks of financial controversy. If one would be still further convinced, listen to the casual conversation of a group of medical men in the physicians' waiting room of a general hospital. The theme of discussion is not so likely to be a recent article of great scientific interest, or the superior investigative work of some struggling young practitioner, but gossip about the volume of work or incomes of supposedly successful specialists.

Too generally the profession has become obsessed with the idea of magnitude, in practice rather than quality of work, or contributions to professional betterment. "Big Business" in medicine, like in the commercial and industrial world, may produce a few medical plutocrats, but its tendency will be to lower the general professional tone, and establish false standards of practice. It is not in keeping with the ancient traditions of medicine, nor consonant with "The Principles of Medical Ethics" that we should bow down before the Mammon of avarice.

Finally, may it not be contended that sufficient argument has been offered to justify the conclusion that there is urgent need, in these times of medical unrest, for a rejuvenation of "The Principles of Medical Ethics"? Let this instrument be considered not merely an epitome of the laws governing the moral conduct of physicians but a living, moving force to promote the ideals of medical progress. As the Decalogue was to the ancient Hebrews, so let the profession of medicine find light and guidance in a revival of "The Ten Commandments of Medical Ethics".

The Ten Commandments of Medical Ethics

1. Reverence and Responsibility.
   Remember thy Creator in the days of professional youth. Bow reverently before the wonderful human body, sick or well, as thou wouldst before a sacred shrine, conscious of thy high duty; resolved to serve to the best of thy power, whether the patient be black or white, prince or pauper, saint or degenerate.
2. Historic Appreciation.
   Honor thy father and thy mother. Likewise give praise to the fathers in medicine whose rich heritage of scientific and clinical truth has been handed down to thee through centuries of patient toil. Hold fast to that which is good, but let not prejudice coming out of the past blind thy vision to the newer truths of medical advancement.
3. Keeping the Faith.
   Thou shalt not worship the graven images of false practice—of avarice and selfishness which eat at the very heart of medical idealism; of clever artifice or brazen quackery which knowingly deceives; of erratic isms and cults which tell but half truths, leading the ignorant and unwary astray.
4. Inviolable Confidences.
   Thou shalt not disclose the secrets confided to thy keeping by trusting patients unless they be of criminal or treasonable import. Nor shalt thou abuse the professional intimacy granted to thee by women, which becomes a professional and moral obligation thou shouldst hold inviolate.
5. The Sanctity of Life.
   Thou shalt not hazard life unwarrantably; neither shalt thou shrink before the obvious perils of duty when life is at stake. The unborn shalt thou not destroy except after due consultation, it is deemed advisable for the larger saving of life. Suffer not death to come through neglect in care of the sick, nor from failure in reading, study and counsel to gain the greatest benefit for the patient.
6. Professional Cooperation.
   Thou shalt not bear false witness against a worthy professional brother, but seek ever to protect his good name from calumnious attack by misinterpreting laymen. Of thy knowledge give him unstintingly, counselling and cooperating for medical progress.
7. Gentlemanly Conduct.
   Thou shalt not prate of cases nor countenance unseemly boasting of thy achievements in the lay press. Always a gentleman, let thy conduct be reserved but without cowardice; courteous but free from flattery; dignified but of warm heart; tender in ministration but firm in command; clean of body, speech and mind.
8. Honesty in Business.
   Thou shalt not steal; neither shalt thou make extortionate charges nor deceive by the secret division of fees. As a laborer worthy of hire exact fair compensation but by open methods and with conscience void of offense toward thy fellow-man.
9. Obligation to One's Own.
   Take heed of the morrow for the sake of thine own flesh and blood. Therefore shalt thou keep orderly accounts, collecting from the full-handed just recompense for services rendered. To the poor and the families of deserving colleagues, thou shouldst account it a privilege to render faithful attention.
10. Personal and Public Service.
    Remember thou art thy brother's keeper— physically in the measures and remedies advised for the prevention, alleviation or healing of disease; spiritually in the cheer thou bringest to heavy hearts and the courage thou givest to halting steps. So walking upright before man, mayest thou shew thyself approved unto God. Thus journeying toward life's end, if not singing with the Psalmist "My cup runneth over," thou wilt at least be sustained by the reflections of "A workman that needeth not be ashamed."

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1. Seventeenth of a series of articles by Dr. Wynn which will appear regularly in The Journal.